Only 46% of rural counties have a hospital that delivers babies
August 9, 2022 6:01 AM Subscribe
“If you go into labor and the hospital is closed, you’re SOL,” she says. “Or say you deliver when the hospital is open, but it’s closing in seven hours. Do we just discharge a 7-hour-old baby? That’s what we’re doing. Our back is against the wall.” A Very Dangerous Place to be Pregnant Has Become Even Scarier. [Bloomberg]
I used to live up the shore from Duluth MN. We had a small clinic in town but the closest place to deliver babies was in Duluth. One of my colleagues had a high-risk pregnancy and, for the last week or so of it, she stayed at a hotel in Duluth.
It's two hours from Grand Marais to Duluth, and that's in daylight, perfect weather, and perfect road conditions. That would be a looooong ride if you were in labor on a snowy night in February. My colleague was lucky in that she could afford to stay in a hotel and was able to be away from family and work for an indeterminate amount of time before the baby came. Most people wouldn't have that option, and would then have to make the long drive while under stress.
posted by Gray Duck at 6:35 AM on August 9, 2022 [12 favorites]
It's two hours from Grand Marais to Duluth, and that's in daylight, perfect weather, and perfect road conditions. That would be a looooong ride if you were in labor on a snowy night in February. My colleague was lucky in that she could afford to stay in a hotel and was able to be away from family and work for an indeterminate amount of time before the baby came. Most people wouldn't have that option, and would then have to make the long drive while under stress.
posted by Gray Duck at 6:35 AM on August 9, 2022 [12 favorites]
Related: A challenge for antiabortion states: Doctors reluctant to work there [WaPo gift link]
Tom Florence, president of Merritt Hawkins, an AMN Healthcare company, cited 20 instances since the Supreme Court ruling where prospects specifically refused to relocate to states where reproductive rights are being targeted by lawmakers.
“To talk to approximately 20 candidates that state they would decline to practice in those restrictive states, that is certainly a trend we are seeing,” Florence said. “It is certainly going to impact things moving forward.”
posted by ryanshepard at 6:44 AM on August 9, 2022 [20 favorites]
Tom Florence, president of Merritt Hawkins, an AMN Healthcare company, cited 20 instances since the Supreme Court ruling where prospects specifically refused to relocate to states where reproductive rights are being targeted by lawmakers.
“To talk to approximately 20 candidates that state they would decline to practice in those restrictive states, that is certainly a trend we are seeing,” Florence said. “It is certainly going to impact things moving forward.”
posted by ryanshepard at 6:44 AM on August 9, 2022 [20 favorites]
I worked with a physician who finished out the end of his career working at a prison. He said when he started his rural practice in the late 70s he delivered a lot of babies. But at some point in the late 80s he stopped due to the staggeringly high malpractice insurance cost. The hospital itself also decided it wasn't interested anymore either, for the same reasons. So now people have to drive half an hour to the nearest hospital with an OB.
posted by drstrangelove at 6:44 AM on August 9, 2022 [7 favorites]
posted by drstrangelove at 6:44 AM on August 9, 2022 [7 favorites]
Forced birth states are having recuitment problems because of it in across the board; it must be worse for healthcare recruitment at all levels but especially nursing which is dominated by uretus having practitioners.
posted by Mitheral at 6:57 AM on August 9, 2022 [13 favorites]
posted by Mitheral at 6:57 AM on August 9, 2022 [13 favorites]
Archived (non-paywalled) version: https://archive.ph/Il06P
posted by robotmachine at 6:58 AM on August 9, 2022 [7 favorites]
posted by robotmachine at 6:58 AM on August 9, 2022 [7 favorites]
Everything is conspiring to make this worse. From a financial perspective, community hospitals don't have the luxury of providing services that lose money and you need to deliver a lot of babies to justify having an L&D unit. OBs and MFMs are retiring faster than new fellows are entering the market, and they tend to gravitate towards urban areas. Pregnancies are getting more complicated. Reimbursement favors diagnostics early in pregnancies rather than the work of delivering babies, so the most highly trained docs (MFMs) tend to read ultrasounds for a living rather than manage complex patients in the hospital. Oh, and good luck with your mental health, food/housing/job security, lining up childcare for your other kids while you travel 4 hours to a major medical center to deliver, paying for your NICU bill, etc.
posted by woof at 7:08 AM on August 9, 2022 [18 favorites]
posted by woof at 7:08 AM on August 9, 2022 [18 favorites]
I'll note that maybe the scary thing is the concept of a "hospital" that closes.
I recently found someone’s lost ID on the street. After an initial search for them online proved fruitless, I reckoned I would drop it off at the police station.
The police in my city close at 10:00 PM.
posted by ricochet biscuit at 7:53 AM on August 9, 2022 [15 favorites]
I recently found someone’s lost ID on the street. After an initial search for them online proved fruitless, I reckoned I would drop it off at the police station.
The police in my city close at 10:00 PM.
posted by ricochet biscuit at 7:53 AM on August 9, 2022 [15 favorites]
This is by design. It makes it easier to control the populace and allows the rent seekers that control the town/county/state to leech off what little the poor have. They make money out of people's desperation like some fucked up legal loan shark.
Fascists don't care if shit is backwards. They don't care if people die. They only care if they have run of the place and can extract from it for their benefit.
posted by Your Childhood Pet Rock at 8:11 AM on August 9, 2022 [17 favorites]
Fascists don't care if shit is backwards. They don't care if people die. They only care if they have run of the place and can extract from it for their benefit.
posted by Your Childhood Pet Rock at 8:11 AM on August 9, 2022 [17 favorites]
For some context:
From 1990 - 2015, the death rates for mothers in childbirth was increasing for the United States but decreasing in other developed nations: U.S. Has The Worst Rate Of Maternal Deaths In The Developed World
Texas is already the US's eighth worst state for maternal deaths: Maternal Mortality Rate by State 2022
posted by meowzilla at 8:11 AM on August 9, 2022 [15 favorites]
From 1990 - 2015, the death rates for mothers in childbirth was increasing for the United States but decreasing in other developed nations: U.S. Has The Worst Rate Of Maternal Deaths In The Developed World
Texas is already the US's eighth worst state for maternal deaths: Maternal Mortality Rate by State 2022
posted by meowzilla at 8:11 AM on August 9, 2022 [15 favorites]
Yeah, this is pretty much on purpose, and it's the entirely predictable outcome of the last forty years of public policy in places like Texas (and most of the rest of the US).
...I mean, people were literally told that this kind of thing would happen. The US had a reasonably good maternal mortality rate, and then went about methodically making everything worse. On purpose. Knowing what was going to happen.
People didn't care then, they don't care now, they're not going to care any time soon, and nobody is going to stand up to make them care because that requires sustained effort and thirty seconds of flag-waving nonsense will offer enough distraction that the effort fades.
posted by aramaic at 8:19 AM on August 9, 2022 [12 favorites]
...I mean, people were literally told that this kind of thing would happen. The US had a reasonably good maternal mortality rate, and then went about methodically making everything worse. On purpose. Knowing what was going to happen.
People didn't care then, they don't care now, they're not going to care any time soon, and nobody is going to stand up to make them care because that requires sustained effort and thirty seconds of flag-waving nonsense will offer enough distraction that the effort fades.
posted by aramaic at 8:19 AM on August 9, 2022 [12 favorites]
It so happens I had my routine six-month checkup here in Indianapolis yesterday, and I spent ten minutes of her valuable time commiserating with her (a woman of childbearing age) about her and her profession being relegated to second-class status by our legislature.
This woman is a family practitioner, doing badly needed work, and I could tell she was having second thoughts about even being here, and who could blame her?
posted by Gelatin at 8:32 AM on August 9, 2022 [18 favorites]
This woman is a family practitioner, doing badly needed work, and I could tell she was having second thoughts about even being here, and who could blame her?
posted by Gelatin at 8:32 AM on August 9, 2022 [18 favorites]
OBs and MFMs are retiring faster than new fellows are entering the market
Doesn't the AMA still control/artificially limit the supply of physicians in the US?
posted by They sucked his brains out! at 9:42 AM on August 9, 2022 [2 favorites]
Doesn't the AMA still control/artificially limit the supply of physicians in the US?
posted by They sucked his brains out! at 9:42 AM on August 9, 2022 [2 favorites]
I could feel my blood pressure rising but forced myself to read to the end.
posted by The Underpants Monster at 9:51 AM on August 9, 2022
posted by The Underpants Monster at 9:51 AM on August 9, 2022
This is so heartbreaking. I literally thought wether I could retrain as a midwife and go help, but it isn't realistic at all, I'm near sixty. And also, isn't it absurd that places in the US need help just like places in Africa, or Syria or Yemen?
posted by mumimor at 10:13 AM on August 9, 2022 [5 favorites]
posted by mumimor at 10:13 AM on August 9, 2022 [5 favorites]
I keep thinking there's got to be some way to get vital services to people of the USA. Even if they live in an area where it's not seen as profitable to run that kind of business.
Probably nothing could be done to help make sure there is access for all of us across the country. I doubt there's even any historically similar situations. I'll just go pour myself a tall glass of milk and think about it.
posted by SaltySalticid at 10:34 AM on August 9, 2022
Probably nothing could be done to help make sure there is access for all of us across the country. I doubt there's even any historically similar situations. I'll just go pour myself a tall glass of milk and think about it.
posted by SaltySalticid at 10:34 AM on August 9, 2022
I live in a big city, Chicago, and my problem is that despite their being hundreds of different primary care physicians and three hospitals and dozens of clinics within walking distance I have never yet seen the same doctor twice. They practice hop, move out, burn out or the practice relocates. I have had zero continuity of care since moving to the US despite have access and decent health insurance. When paxlovid first came out and they said "Get your family doctor, who knows your medical history, to prescribe it" I just laughed. No matter who you are or where in this country you live the American healthcare system will somehow find a way to be really crap for you. You'd almost think it was one of their KPIs.
posted by srboisvert at 10:52 AM on August 9, 2022 [9 favorites]
posted by srboisvert at 10:52 AM on August 9, 2022 [9 favorites]
Going on a limb perhaps but in my opinion, it would be great to assess and standardize at the Medicare reimbursement level what type of medical coverage is needed/expected in USA regions of varying size. And it will be a huge endeavor to align expectations of what's possible vs what's good enough" among patients/families vs specialists vs actuaries (see cancer screening/treatment discussions). And the lack of facilities due to consolidation by ownership or lack of local supporting taxes will also need addressed and is often a greater problem than staffing in non-COVID times.
A core issue, imo, is that most USA small towns/rural and wilderness areas need fam practice and ER doctors but aren't going to be able to financially support multiple specialists, including OB, peds, and oncology, (and if specialists are actually needed, then 2 may be needed to cover 24/7/365 coverage including vacations, sick days, holidays, etc) (and if such specialists are financially thriving in such rural/wilderness areas these days, I'm always suspicious of their billing/lab ordering practices.)
But while fam prac docs can actually do most OB/Gyn and pedi care, I can understand chemo pts wishing to stay within the specialty, thus driving corporate hospitals to build specialty facilities in outlying areas but these are often limited to the specialty and may be closed if demand drops or it becomes too expensive to upgrade.
Circuit docs used to be around until the 1800s (which is essentially what the doc is the article is) but the counties of Texas and Montana etc where as few as 200 people live have always and will always travel for health care.
That telemedicine has not better survived post-COVID is an absolute travesty.
Any recs for detailed reviews on how other countries address coverage in rural and wilderness areas? Greater use of clinics (not hospitals) and of paraprofessionals? Different expectations of what reasonable coverage consists of?
posted by beaning at 11:16 AM on August 9, 2022 [1 favorite]
A core issue, imo, is that most USA small towns/rural and wilderness areas need fam practice and ER doctors but aren't going to be able to financially support multiple specialists, including OB, peds, and oncology, (and if specialists are actually needed, then 2 may be needed to cover 24/7/365 coverage including vacations, sick days, holidays, etc) (and if such specialists are financially thriving in such rural/wilderness areas these days, I'm always suspicious of their billing/lab ordering practices.)
But while fam prac docs can actually do most OB/Gyn and pedi care, I can understand chemo pts wishing to stay within the specialty, thus driving corporate hospitals to build specialty facilities in outlying areas but these are often limited to the specialty and may be closed if demand drops or it becomes too expensive to upgrade.
Circuit docs used to be around until the 1800s (which is essentially what the doc is the article is) but the counties of Texas and Montana etc where as few as 200 people live have always and will always travel for health care.
That telemedicine has not better survived post-COVID is an absolute travesty.
Any recs for detailed reviews on how other countries address coverage in rural and wilderness areas? Greater use of clinics (not hospitals) and of paraprofessionals? Different expectations of what reasonable coverage consists of?
posted by beaning at 11:16 AM on August 9, 2022 [1 favorite]
Any recs for detailed reviews on how other countries address coverage in rural and wilderness areas?Is there another "developed" country that has the huge rural footprint and thinly distributed population of the USA? Canada has the wilderness, but not the population, and its population is extremely concentrated in urban centers anyway. Europe is obvs. much more compact.
I think you'd have to look at the BRIC (Brazil, Russia, India, China) to find geographic comparables.
posted by Sauce Trough at 11:29 AM on August 9, 2022 [1 favorite]
I keep thinking there's got to be some way to get vital services to people of the USA. Even if they live in an area where it's not seen as profitable to run that kind of business.
I mean, yes, of course there is, but it involves taxing people and "people" (corporations) who can well afford to pay taxes and using that money to help everybody. And it involves getting rid of corrupt politicians like the ones in Texas who voted to decline assistance to expand coverage. It's an uphill battle. It's no coincidence that the decline in health outcomes started in the Reagan era.
posted by The Underpants Monster at 11:41 AM on August 9, 2022 [13 favorites]
I mean, yes, of course there is, but it involves taxing people and "people" (corporations) who can well afford to pay taxes and using that money to help everybody. And it involves getting rid of corrupt politicians like the ones in Texas who voted to decline assistance to expand coverage. It's an uphill battle. It's no coincidence that the decline in health outcomes started in the Reagan era.
posted by The Underpants Monster at 11:41 AM on August 9, 2022 [13 favorites]
I keep thinking there's got to be some way to get vital services to people of the USA. Even if they live in an area where it's not seen as profitable to run that kind of business.
There is! It's called a "government," which is supposed to promote the general welfare of everyone in the nation, but unfortunately it's half run by a political party that wants to limit public resources to those it deems "deserving."
posted by Gelatin at 11:52 AM on August 9, 2022 [27 favorites]
There is! It's called a "government," which is supposed to promote the general welfare of everyone in the nation, but unfortunately it's half run by a political party that wants to limit public resources to those it deems "deserving."
posted by Gelatin at 11:52 AM on August 9, 2022 [27 favorites]
Gray Duck: It's two hours from Grand Marais to Duluth.... That would be a looooong ride if you were in labor on a snowy night in February
A few years ago my mom's nose started bleeding when they were driving back to the Twin Cities from the lake, and they drove or an hour before they could find a hospital. A local cop (sheriff, maybe) drove with them for part of it to get them to a ER that could just pack her nose.
It was a sobering thing, because it was "just a bloody nose" on a summer weekend afternoon -- but seen another way, it was "uncontrolled bleeding" and if it had been a saw accident or something, there would have been a death.
posted by wenestvedt at 12:03 PM on August 9, 2022 [3 favorites]
A few years ago my mom's nose started bleeding when they were driving back to the Twin Cities from the lake, and they drove or an hour before they could find a hospital. A local cop (sheriff, maybe) drove with them for part of it to get them to a ER that could just pack her nose.
It was a sobering thing, because it was "just a bloody nose" on a summer weekend afternoon -- but seen another way, it was "uncontrolled bleeding" and if it had been a saw accident or something, there would have been a death.
posted by wenestvedt at 12:03 PM on August 9, 2022 [3 favorites]
srboisvert: I have had zero continuity of care...
I hear you, it's awful!
My kids are college-age, and their pediatrician is still treating them because we can't find primary care doctors for them without interrupting ongoing care. There are very few to choose from, and that's with really good coverage. (*makes the sign of the cross, kisses the insurance card hanging around my neck*)
Health insurance in America as A Thing is total bullshit.
--
One of my kids is starting college and wants to eventually become a Physician Assistant. I suggested that he might get the chance to serve as a small town doctor in somewhere beautiful and outdoorsy, with the supervising doctor an hour away in The Big City. PAs are one of the few plausible solutions to the "No M.D. wants to live and work here" issue that I have heard, with their two-year course of study.
posted by wenestvedt at 12:12 PM on August 9, 2022 [6 favorites]
I hear you, it's awful!
My kids are college-age, and their pediatrician is still treating them because we can't find primary care doctors for them without interrupting ongoing care. There are very few to choose from, and that's with really good coverage. (*makes the sign of the cross, kisses the insurance card hanging around my neck*)
Health insurance in America as A Thing is total bullshit.
--
One of my kids is starting college and wants to eventually become a Physician Assistant. I suggested that he might get the chance to serve as a small town doctor in somewhere beautiful and outdoorsy, with the supervising doctor an hour away in The Big City. PAs are one of the few plausible solutions to the "No M.D. wants to live and work here" issue that I have heard, with their two-year course of study.
posted by wenestvedt at 12:12 PM on August 9, 2022 [6 favorites]
Is there another "developed" country that has the huge rural footprint and thinly distributed population of the USA?
Australia, I thought? Depends exactly what you’re measuring.
posted by clew at 12:19 PM on August 9, 2022 [4 favorites]
Australia, I thought? Depends exactly what you’re measuring.
posted by clew at 12:19 PM on August 9, 2022 [4 favorites]
When I was much younger and more naive I used to be pro-life. But the bullshit in that movement turned it around.
The fact that pro-life leaders/politicians rarely talk about how we can ease being a mother and having young children disgusted me. They could attract more fencesitters just by acknowledging reality.
When was the last time the leaders (not average people who don't write policy) talked about the following?
-More daycares with higher pay
-More childcare subsidies/tax credits
-More early education (so parents can work and catch a break)
-Better adoption and foster care resources (adoptions should be celebrated!)
The fact that too many places can't even support new life is telling.
Calling women dumb hos is just too much of a distraction for leaders who claim to be worried about "babies". I'm tired.
posted by Freecola at 12:28 PM on August 9, 2022 [4 favorites]
The fact that pro-life leaders/politicians rarely talk about how we can ease being a mother and having young children disgusted me. They could attract more fencesitters just by acknowledging reality.
When was the last time the leaders (not average people who don't write policy) talked about the following?
-More daycares with higher pay
-More childcare subsidies/tax credits
-More early education (so parents can work and catch a break)
-Better adoption and foster care resources (adoptions should be celebrated!)
The fact that too many places can't even support new life is telling.
Calling women dumb hos is just too much of a distraction for leaders who claim to be worried about "babies". I'm tired.
posted by Freecola at 12:28 PM on August 9, 2022 [4 favorites]
Is there another "developed" country that has the huge rural footprint and thinly distributed population of the USA? Canada has the wilderness, but not the population, and its population is extremely concentrated in urban centers anyway. Europe is obvs. much more compact.
For Australia it's a mix of strategies. In the case of GPs where they're run independently as small businesses, Medicare provides extra payments to GPs per consultation in rural areas based on zone. For hospitals which are state run and a mix of state and federally funded, the Commonwealth fronts a fuckton of cash to incentivize docs to go rural.
The common factor? Pay the doctors more money for having to live in places with less services.
posted by Your Childhood Pet Rock at 12:30 PM on August 9, 2022 [16 favorites]
For Australia it's a mix of strategies. In the case of GPs where they're run independently as small businesses, Medicare provides extra payments to GPs per consultation in rural areas based on zone. For hospitals which are state run and a mix of state and federally funded, the Commonwealth fronts a fuckton of cash to incentivize docs to go rural.
The common factor? Pay the doctors more money for having to live in places with less services.
posted by Your Childhood Pet Rock at 12:30 PM on August 9, 2022 [16 favorites]
For Australia it's a mix of strategies. In the case of GPs where they're run independently as small businesses, Medicare provides extra payments to rural areas based on zone. For hospitals which are state run and a mix of state and federally funded, paying a fuckton of cash to incentivize docs to go rural.
The common factor? Pay the doctors more money for having to live in places with less services.
Drilling down to the devilish details, what's the determining factor(s) for if a specialty is needed in a given area? Are oncologists and heart surgeons distributed the same as family prac and internists? Is supporting staff also incentivized? What types of clinics/hospitals are there in these rural areas by zone? ERs with emergency surgery levels and delivery rooms and general observation rooms for non-ICU level care?
What I'm driving at is (a) everywhere can't be big-city/tertiary care center level of specialist offerings and (b) who, whether in a nationalized or private insurance health care system, makes those decisions about what level care is needed and (c) how are citizens educated to accept the level of care they need vs what is highest possible. Right now in the USA, location of services outside of medical centers is driven by the noise of the crowd + where the insurers feel they can make money, and though the crowd requests indicate need of access, neither is a truly reliable indicator of need of specialists. What types of specialist care should be expected to be routinely available in a town of 6000 people vs an urban setting?
USA located patients and insurers have a focus on needing specialists even in rural/wilderness areas when imo the focus should be on greater utilization of and payments for broadly-skilled fam pracs, internists, physician assistants, nurse practitioners and midwives - all of whom who can fill the need with telemedicine access to higher level specialists. The facilities are a separate issue than the staffing.
And thank you to those offering info on other countries. I'll look into BRIC.
posted by beaning at 1:05 PM on August 9, 2022 [3 favorites]
The common factor? Pay the doctors more money for having to live in places with less services.
Drilling down to the devilish details, what's the determining factor(s) for if a specialty is needed in a given area? Are oncologists and heart surgeons distributed the same as family prac and internists? Is supporting staff also incentivized? What types of clinics/hospitals are there in these rural areas by zone? ERs with emergency surgery levels and delivery rooms and general observation rooms for non-ICU level care?
What I'm driving at is (a) everywhere can't be big-city/tertiary care center level of specialist offerings and (b) who, whether in a nationalized or private insurance health care system, makes those decisions about what level care is needed and (c) how are citizens educated to accept the level of care they need vs what is highest possible. Right now in the USA, location of services outside of medical centers is driven by the noise of the crowd + where the insurers feel they can make money, and though the crowd requests indicate need of access, neither is a truly reliable indicator of need of specialists. What types of specialist care should be expected to be routinely available in a town of 6000 people vs an urban setting?
USA located patients and insurers have a focus on needing specialists even in rural/wilderness areas when imo the focus should be on greater utilization of and payments for broadly-skilled fam pracs, internists, physician assistants, nurse practitioners and midwives - all of whom who can fill the need with telemedicine access to higher level specialists. The facilities are a separate issue than the staffing.
And thank you to those offering info on other countries. I'll look into BRIC.
posted by beaning at 1:05 PM on August 9, 2022 [3 favorites]
The medical center is owned by Grant Avenue Capital LLC, so they are not in the buisness of being a hospital they are in the buisness of increasing shareholder value.
posted by kzin602 at 1:12 PM on August 9, 2022 [11 favorites]
posted by kzin602 at 1:12 PM on August 9, 2022 [11 favorites]
I found The Hospital to an interesting (but not without issues) well written read from the overview of a hospital admin in a rural Ohio town that is well utilized for local OB and ER care but is triangulated by larger hospitals within 1-2 hours drive time and the pressures facing him/it from 2019-ending with the start of COVID. The hospital admin makes decisions usually from a good heart coupled with a practical business sense but these don't always play out well esp for chronic care patients. Not to mention prominent citizens' beliefs in the 1900s about "worthiness" of public healthcare for the poor vs ability of clinicians to make money that are still being debated and affecting service decisions 120 yrs later.
I've worked in and around various aspects of OB medicine since I was 16 yrs old, in rural settings, private clinics in medium-sized cities, and world-renowned medical centers. I felt the descriptions of the pressure to keep up with nearby city hospitals (and the national and international comparators) rang true across all places I've worked and agree that this pressure drives much decision making about which specialists to hire/fire, which services those specialists should offer (no MFM here is just reading sonograms all day!), staffing levels, whether the hospital/clinic should stay open as an independent, stay open at all, or be sold to a larger organization, etc.
I've no answers esp for the thinly populated areas which deserve care but lack full resources to pay for it. But I do think it starts with expectations about service levels and the staff to provide it. Taxes for funding will obviously be needed. But as always, does the value/ethic drive the budget or vice versa? Show me the budget and I'll show you what is valued.
posted by beaning at 2:02 PM on August 9, 2022 [4 favorites]
I've worked in and around various aspects of OB medicine since I was 16 yrs old, in rural settings, private clinics in medium-sized cities, and world-renowned medical centers. I felt the descriptions of the pressure to keep up with nearby city hospitals (and the national and international comparators) rang true across all places I've worked and agree that this pressure drives much decision making about which specialists to hire/fire, which services those specialists should offer (no MFM here is just reading sonograms all day!), staffing levels, whether the hospital/clinic should stay open as an independent, stay open at all, or be sold to a larger organization, etc.
I've no answers esp for the thinly populated areas which deserve care but lack full resources to pay for it. But I do think it starts with expectations about service levels and the staff to provide it. Taxes for funding will obviously be needed. But as always, does the value/ethic drive the budget or vice versa? Show me the budget and I'll show you what is valued.
posted by beaning at 2:02 PM on August 9, 2022 [4 favorites]
It's not just rural OB/Gyn care that is in crisis, it's the whole system. It's already mid-collapse in the US. Cities are *very much* affected too, and the general public has no idea. Hospitals are understaffed because they refuse to raise nurses' pay to adequately recruit and retain them. (And the administrators who make the decisions to keep the pay low are rewarded with bonuses for doing so).
Recently I read on the r/nursing subreddit that it's so bad that in some cases now patients are having to have their relatives bring in their medications and they have had to manage taking them entirely themselves, because the hospital pharmacies are also dangerously understaffed and hanging on by a thread.
There are bad stories on the r/medicine subreddit as well. The system is crumbling. Take a look if you don't believe me. There's a drumbeat of threads daily, with nurses and other medical professionals chiming in about how their situation is fucked as well. It's everywhere.
My advice: don't get sick, and don't do anything risky that could result in a serious injury.
Hospitals are not able to provide adequate care anymore, and it's getting more severe and more common. The nurses are stretched too thin, and it's not going to get any better - in fact many many more are leaving the bedside or leaving the profession entirely now, and who can blame them? Being bullied into giving substandard care because patient ratios are just too dangerous is causing them moral injury. They got into the profession to care for people, and now they can't do it adequately and people are dying and having severe negative outcomes because of it.
And their very licenses are on the line. (Hospitals don't hesitate to throw nurses under the bus, even when they foist 10 patients on them when they can only safely care for 5, that kind of thing). But hey, someone making decisions gets a bonus, so that's all that matters in our system with these perverse incentives.
posted by cats are weird at 4:44 PM on August 9, 2022 [14 favorites]
Recently I read on the r/nursing subreddit that it's so bad that in some cases now patients are having to have their relatives bring in their medications and they have had to manage taking them entirely themselves, because the hospital pharmacies are also dangerously understaffed and hanging on by a thread.
There are bad stories on the r/medicine subreddit as well. The system is crumbling. Take a look if you don't believe me. There's a drumbeat of threads daily, with nurses and other medical professionals chiming in about how their situation is fucked as well. It's everywhere.
My advice: don't get sick, and don't do anything risky that could result in a serious injury.
Hospitals are not able to provide adequate care anymore, and it's getting more severe and more common. The nurses are stretched too thin, and it's not going to get any better - in fact many many more are leaving the bedside or leaving the profession entirely now, and who can blame them? Being bullied into giving substandard care because patient ratios are just too dangerous is causing them moral injury. They got into the profession to care for people, and now they can't do it adequately and people are dying and having severe negative outcomes because of it.
And their very licenses are on the line. (Hospitals don't hesitate to throw nurses under the bus, even when they foist 10 patients on them when they can only safely care for 5, that kind of thing). But hey, someone making decisions gets a bonus, so that's all that matters in our system with these perverse incentives.
posted by cats are weird at 4:44 PM on August 9, 2022 [14 favorites]
Forgot to mention severe supply-chain issues and outright failures are causing lots of problems as well. Things like CT contrast dye are being rationed due to shortages. I read yesterday of a hospital that ran out of morphine. Stuff like that. Be careful, folks. It's not the same care you would have gotten in 2019.
posted by cats are weird at 4:47 PM on August 9, 2022 [1 favorite]
posted by cats are weird at 4:47 PM on August 9, 2022 [1 favorite]
Just got a message last week that my endocrinologist of nearly 30 years, who was my primary care physician for over half of those before my insurance changed, is retiring at the end of this month and I’m freaking the hell out.
posted by The Underpants Monster at 5:29 PM on August 9, 2022 [2 favorites]
posted by The Underpants Monster at 5:29 PM on August 9, 2022 [2 favorites]
And also, isn't it absurd that places in the US need help just like places in Africa, or Syria or Yemen?
Doctors without Borders (MSF) has operated in the US in 2020 during the pandemic. But I'm not sure they're keen on running clinics where they may run afoul of local laws, and there is a hostile (and well-armed) local government and population.
posted by meowzilla at 5:30 PM on August 9, 2022 [3 favorites]
Doctors without Borders (MSF) has operated in the US in 2020 during the pandemic. But I'm not sure they're keen on running clinics where they may run afoul of local laws, and there is a hostile (and well-armed) local government and population.
posted by meowzilla at 5:30 PM on August 9, 2022 [3 favorites]
That is what rural Americans continually vote for. Any poll will show you they want capitalist markets to control access to healthcare.
posted by AJScease at 6:03 PM on August 9, 2022 [3 favorites]
posted by AJScease at 6:03 PM on August 9, 2022 [3 favorites]
Is there another "developed" country that has the huge rural footprint and thinly distributed population of the USA? Canada has the wilderness, but not the population, and its population is extremely concentrated in urban centers anyway. Europe is obvs. much more compact.
I think you'd have to look at the BRIC (Brazil, Russia, India, China) to find geographic comparables.
Australia.
posted by carriage pulled by cassowaries at 6:42 PM on August 9, 2022
I think you'd have to look at the BRIC (Brazil, Russia, India, China) to find geographic comparables.
Australia.
posted by carriage pulled by cassowaries at 6:42 PM on August 9, 2022
There is! It's called a "government,"
Absolutely! I see I missed my /sarcasm tag or was too opaque with my bitter joke. When the US govt thought it would be hard for their people to have access to cow milk, they took decisive action and launched a massive investment program in 1949 to make sure we all had that sweet, cheap, cow juice readily available.
We did it for milk, but can't/won't for basic healthcare for women and children, was my shameful point.
posted by SaltySalticid at 7:37 PM on August 9, 2022 [7 favorites]
Absolutely! I see I missed my /sarcasm tag or was too opaque with my bitter joke. When the US govt thought it would be hard for their people to have access to cow milk, they took decisive action and launched a massive investment program in 1949 to make sure we all had that sweet, cheap, cow juice readily available.
We did it for milk, but can't/won't for basic healthcare for women and children, was my shameful point.
posted by SaltySalticid at 7:37 PM on August 9, 2022 [7 favorites]
Re: Australia...
Australia attacks the problem of rural healthcare access by mandating all overseas born doctors fulfil 10 years service in rural areas before being granted the right to work in the cities - even if those doctors are citizens or permanent residents of Australia, they aren't exempt from this rule.
But that's pretty much stealing doctors from neighbouring developing countries in India / South East Asia to improve health outcomes in rural Australia, which I'm kind of iffy about.
Of course, this worked all the way up to the Covid border closures, which cut off the inflow of overseas doctors... I have a family member who says their GP clinic now turns away 50 requests for appointments per day, and is on the verge of going bankrupt because they're paying rent and overheads (support staff etc) for a building that should be running with 6-8 doctors but they only have 3 doctors and are unable to hire more.
In the most remote place they worked in, which was a one street town of 1000 people about 5 hours from the nearest capital, they were given free rent in one of the houses in town, among other incentives. Similar incentives exist for non-GP specialists as well. There is a remoteness ranking and scaled incentives.
As a previous commenter implied, rather than the invisible hand of the free market, decisions about resource allocation are made in a rather opaque fashion by the government "in consultation" with peak medical bodies, which sometimes results in inexplicable upgrading / downgrading of the remoteness rating and hence financial incentives.
The town with the clinic turning away 50 appointments per day was recently downgraded and lost most of the financial incentives, which led to several doctors quitting and moving elsewhere. At best it's ignorance and incompetence on the part of the bureaucrats making those decisions, at worst it's corruption or political games being played to sway the electorate.
posted by xdvesper at 9:06 PM on August 9, 2022 [8 favorites]
Australia attacks the problem of rural healthcare access by mandating all overseas born doctors fulfil 10 years service in rural areas before being granted the right to work in the cities - even if those doctors are citizens or permanent residents of Australia, they aren't exempt from this rule.
But that's pretty much stealing doctors from neighbouring developing countries in India / South East Asia to improve health outcomes in rural Australia, which I'm kind of iffy about.
Of course, this worked all the way up to the Covid border closures, which cut off the inflow of overseas doctors... I have a family member who says their GP clinic now turns away 50 requests for appointments per day, and is on the verge of going bankrupt because they're paying rent and overheads (support staff etc) for a building that should be running with 6-8 doctors but they only have 3 doctors and are unable to hire more.
In the most remote place they worked in, which was a one street town of 1000 people about 5 hours from the nearest capital, they were given free rent in one of the houses in town, among other incentives. Similar incentives exist for non-GP specialists as well. There is a remoteness ranking and scaled incentives.
As a previous commenter implied, rather than the invisible hand of the free market, decisions about resource allocation are made in a rather opaque fashion by the government "in consultation" with peak medical bodies, which sometimes results in inexplicable upgrading / downgrading of the remoteness rating and hence financial incentives.
The town with the clinic turning away 50 appointments per day was recently downgraded and lost most of the financial incentives, which led to several doctors quitting and moving elsewhere. At best it's ignorance and incompetence on the part of the bureaucrats making those decisions, at worst it's corruption or political games being played to sway the electorate.
posted by xdvesper at 9:06 PM on August 9, 2022 [8 favorites]
Another thorny issue is that many remote towns simply don't have enough patients to support the ongoing training, or even maintaining of skills of those doctors.
For example, a GP in training working in a remote town will see about about 1/5 as many patients per day as a doctor in a busier town. Yes, the government will pay you the other 4/5 of the time you are idle, but money was never the main point... working at this pace, you gain experience 1/5 as fast, which means, when it comes to the qualifying exams, you're very likely going to fail to get your qualifications due to your inexperience. Fail enough times and you can even get kicked out of the training program, because you aren't worth wasting their time.
Doctors working 14-16 hours per day is common because that's the amount of experience / training you need to master the skills necessary under the guidance of your teachers. If you only do 8 hours a day, you'll either go into your exams half as prepared, or take twice as long to complete those exams. Getting fully qualified ALREADY takes about 10 years after leaving university, no one wants it to take even longer than that...
I've heard of specialists (as per the article, obstetricians) having to leave rural towns because they just didn't get enough births for them to maintain confidence in their skills. Nothing to do with pay, or remoteness, just simply the deterioration of their skills that they aren't practicing.
posted by xdvesper at 10:05 PM on August 9, 2022 [3 favorites]
For example, a GP in training working in a remote town will see about about 1/5 as many patients per day as a doctor in a busier town. Yes, the government will pay you the other 4/5 of the time you are idle, but money was never the main point... working at this pace, you gain experience 1/5 as fast, which means, when it comes to the qualifying exams, you're very likely going to fail to get your qualifications due to your inexperience. Fail enough times and you can even get kicked out of the training program, because you aren't worth wasting their time.
Doctors working 14-16 hours per day is common because that's the amount of experience / training you need to master the skills necessary under the guidance of your teachers. If you only do 8 hours a day, you'll either go into your exams half as prepared, or take twice as long to complete those exams. Getting fully qualified ALREADY takes about 10 years after leaving university, no one wants it to take even longer than that...
I've heard of specialists (as per the article, obstetricians) having to leave rural towns because they just didn't get enough births for them to maintain confidence in their skills. Nothing to do with pay, or remoteness, just simply the deterioration of their skills that they aren't practicing.
posted by xdvesper at 10:05 PM on August 9, 2022 [3 favorites]
I'm hoping someone from Norway, Sweden and Finland will chip in here, because they have vast empty lands there, too. And good health outcomes. I know a lot of medical professionals from Denmark go to Norway to work, for better pay and work conditions. (Though it is part of the story that lots of young Norwegians study in Denmark, so they are in effect going back home).
I think the lack of doctors and nurses is a global thing that was made apparent by COVID, but that it is a result of bad planning decades ago. I mean, if you need more nurses now, today is far too late to incentivize young people to go to school, and for specialist nurses and doctors, the planning has to begin a decade before the need is there.
The 00s were an age of really bad or no planning, for ideological reasons as well as for profiteering. I can't think of a single country that did the work. Anecdotally, I was working in a little corner of hospital planning back then, and I remember a delegation from the Danish parliament going to the US on a study trip. Like seriously, you are all going to see how they do in a country with far worse outcomes than here? What are you studying? The answer was of course, how to create a private health sector. And a privately run health sector is of course unable to do planning at a societal level, for all the reasons mentioned in TFA and in comments above.
posted by mumimor at 2:40 AM on August 10, 2022 [6 favorites]
I think the lack of doctors and nurses is a global thing that was made apparent by COVID, but that it is a result of bad planning decades ago. I mean, if you need more nurses now, today is far too late to incentivize young people to go to school, and for specialist nurses and doctors, the planning has to begin a decade before the need is there.
The 00s were an age of really bad or no planning, for ideological reasons as well as for profiteering. I can't think of a single country that did the work. Anecdotally, I was working in a little corner of hospital planning back then, and I remember a delegation from the Danish parliament going to the US on a study trip. Like seriously, you are all going to see how they do in a country with far worse outcomes than here? What are you studying? The answer was of course, how to create a private health sector. And a privately run health sector is of course unable to do planning at a societal level, for all the reasons mentioned in TFA and in comments above.
posted by mumimor at 2:40 AM on August 10, 2022 [6 favorites]
I did some marketing for a college nursing program 15 years ago that was overwhelmed by students and short on professors. Apparently it was a nationwide problem.
I was told that was just the way things were, as though opening more schools and paying people more to teach was just something that couldn't happen.
posted by emjaybee at 7:07 AM on August 10, 2022 [2 favorites]
I was told that was just the way things were, as though opening more schools and paying people more to teach was just something that couldn't happen.
posted by emjaybee at 7:07 AM on August 10, 2022 [2 favorites]
Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit.
As noted above, this is a private hospital, run for profit. They certainly could provide these services by providing better pay, child care, and so on. However, these services would run at a “loss” - that is, the investors would make less money. The company and the state politicians obviously value peoples’ lives and health at $0. It should be noted that the Big Bend area is predominantly Tejano and poor.
This is the main malignancy eating the US health care system. I’m old enough to remember and have worked in community hospitals which were supported by the community with money from local government to help defray the care of the poor, volunteer work, fund raisers, gifts and endowments by local families, and so on. Our own small hospital non-profit system (<200 beds) received ~$2 million a year from the county, had tax abatements, and had property and money gifted to it. It didn’t make a Wall Street level of money but did well as compared to other non-profit hospital systems.
Yet, in the last few years, this community developed and supported hospital system was acquired by a larger corporate entity. It is unclear to me where the money went but I have my suspicions. Care has declined and there has been a flight of physicians, including me, and nurses. Now, a substantial number of nurses are “traveling” nurses. As an example of corporate care, our ICU medical staff - which consisted of multiply-boarded pulmonologists/critical care physicians - was replaced with a contracted group of doctors who supervise ICU patients by telemedicine! I kid you not. The hospital hired nurse practitioners who go to the bedside and communicate remotely with the MDs then adjust the ventilators, drips, etc. The few remaining pulmonologists cannot even manage their own patients if they are admitted to the ICU as they (and every other doctor except the hired staff) do not have ‘privileges’ for ICU care. They do however get called in from time to time to do a bronchoscopy. Yet, apparently, this type of system makes the corporate parent more money (in this case because the hospital employs the NPs and can bill for their services as physicians because they are supervised by an MD, albeit 2 time zones away.)
The problem of declining OB-Gyn physician numbers has been going for over 20 years. Locally, even at that time, most “OBs” did not do obstetrics. Too risky, to much expense for insurance, too erratic hours; they did only gynecology and surgery. It is a slow motion collapse, driven by perverse incentives as smaller hospitals, physicians, nurses, and other professionals try try navigate the system which is designed for profitability instead of for care.
posted by sudogeek at 8:04 AM on August 10, 2022 [10 favorites]
As noted above, this is a private hospital, run for profit. They certainly could provide these services by providing better pay, child care, and so on. However, these services would run at a “loss” - that is, the investors would make less money. The company and the state politicians obviously value peoples’ lives and health at $0. It should be noted that the Big Bend area is predominantly Tejano and poor.
This is the main malignancy eating the US health care system. I’m old enough to remember and have worked in community hospitals which were supported by the community with money from local government to help defray the care of the poor, volunteer work, fund raisers, gifts and endowments by local families, and so on. Our own small hospital non-profit system (<200 beds) received ~$2 million a year from the county, had tax abatements, and had property and money gifted to it. It didn’t make a Wall Street level of money but did well as compared to other non-profit hospital systems.
Yet, in the last few years, this community developed and supported hospital system was acquired by a larger corporate entity. It is unclear to me where the money went but I have my suspicions. Care has declined and there has been a flight of physicians, including me, and nurses. Now, a substantial number of nurses are “traveling” nurses. As an example of corporate care, our ICU medical staff - which consisted of multiply-boarded pulmonologists/critical care physicians - was replaced with a contracted group of doctors who supervise ICU patients by telemedicine! I kid you not. The hospital hired nurse practitioners who go to the bedside and communicate remotely with the MDs then adjust the ventilators, drips, etc. The few remaining pulmonologists cannot even manage their own patients if they are admitted to the ICU as they (and every other doctor except the hired staff) do not have ‘privileges’ for ICU care. They do however get called in from time to time to do a bronchoscopy. Yet, apparently, this type of system makes the corporate parent more money (in this case because the hospital employs the NPs and can bill for their services as physicians because they are supervised by an MD, albeit 2 time zones away.)
The problem of declining OB-Gyn physician numbers has been going for over 20 years. Locally, even at that time, most “OBs” did not do obstetrics. Too risky, to much expense for insurance, too erratic hours; they did only gynecology and surgery. It is a slow motion collapse, driven by perverse incentives as smaller hospitals, physicians, nurses, and other professionals try try navigate the system which is designed for profitability instead of for care.
posted by sudogeek at 8:04 AM on August 10, 2022 [10 favorites]
In Illinois, a lot of the legacy rural ERs are staffed by two or three full-time doctors, and they are mostly doctors from other countries (often India) who receive green cards in exchange for five years' service in a rural hospital. There will be one or two doctors on a 12-hour day shift, and one guy on a 12-hour night shift. They do GP stuff by appointment during the day, but it isn't enough to keep a whole doctor busy, and at night, it's just the one guy and a few nurses. This is part of why Peoria has a large, nice Hindu temple; there are plenty of Hindus in Peoria (between Caterpillar and Bradley U and the hospitals), but there are lots and lots serving as doctors in rural areas who want to visit a temple now and then.
But under the Trump administration it got a lot harder to recruit those doctors, and get them the immigration paperwork necessary. And like, it's already a big ask! "Go move to rural Illinois, to a town you've never heard of, three hours by car from Chicago, where you will be the only person of color in the town. Some people will be really nice, but others are going to be VERY weird about your accent. Ask your spouse to move there, where there are no other jobs for someone with a college degree. Ask your children to move there, where there's no school, and your kids will ride the bus for 40 minutes to another town. There is no Indian grocery; you will have to drive 90 minutes to the nearest supermarket with Indian food. You may have to drive 30 minutes to get to a grocery store at all."
Under Trump, it got harder and harder for the hospitals to get permission to recruit foreign doctors, and to be able to guarantee them green cards. And I love the midwest, and I will stan it at length, but living in the rural midwest is a very specific life choice that isn't for everyone, and can be a huge culture shock for people coming from abroad. Rural Indiana has a surprisingly large population of immigrants from Sudan; farming in Indiana is relatively similar to Sudan, and Sudanese farmers who were resettled in Indiana liked it a lot and told their families and friends. That's amazing! But far more common is things like, a friend of mine from Israel moved to suburban Chicago, and she was constantly like, "Why is this not a first-world nation? Why does the power keep going out for no reason? Are you not the superpower?" (And I was like, "Let me tell you a little story about the time the feds shut down Commonwealth Edison's nuclear plant because they were too terrifyingly incompetent to run it ...")
With my third baby, I lived six minutes from the hospital. We both would have died if it had been fifteen minutes. (Possibly even 10 minutes.) I would not have gotten pregnant if I lived 40 minutes from a hospital. Other people make the same calculus.
posted by Eyebrows McGee at 5:54 PM on August 10, 2022 [7 favorites]
But under the Trump administration it got a lot harder to recruit those doctors, and get them the immigration paperwork necessary. And like, it's already a big ask! "Go move to rural Illinois, to a town you've never heard of, three hours by car from Chicago, where you will be the only person of color in the town. Some people will be really nice, but others are going to be VERY weird about your accent. Ask your spouse to move there, where there are no other jobs for someone with a college degree. Ask your children to move there, where there's no school, and your kids will ride the bus for 40 minutes to another town. There is no Indian grocery; you will have to drive 90 minutes to the nearest supermarket with Indian food. You may have to drive 30 minutes to get to a grocery store at all."
Under Trump, it got harder and harder for the hospitals to get permission to recruit foreign doctors, and to be able to guarantee them green cards. And I love the midwest, and I will stan it at length, but living in the rural midwest is a very specific life choice that isn't for everyone, and can be a huge culture shock for people coming from abroad. Rural Indiana has a surprisingly large population of immigrants from Sudan; farming in Indiana is relatively similar to Sudan, and Sudanese farmers who were resettled in Indiana liked it a lot and told their families and friends. That's amazing! But far more common is things like, a friend of mine from Israel moved to suburban Chicago, and she was constantly like, "Why is this not a first-world nation? Why does the power keep going out for no reason? Are you not the superpower?" (And I was like, "Let me tell you a little story about the time the feds shut down Commonwealth Edison's nuclear plant because they were too terrifyingly incompetent to run it ...")
With my third baby, I lived six minutes from the hospital. We both would have died if it had been fifteen minutes. (Possibly even 10 minutes.) I would not have gotten pregnant if I lived 40 minutes from a hospital. Other people make the same calculus.
posted by Eyebrows McGee at 5:54 PM on August 10, 2022 [7 favorites]
When I was growing up in farm country, the nearest doctor was two towns away, having come to the US on one of those same immigration incentive programs. For some reason I never quite understood, he had been a surgeon in India but was now working as a rural GP and seemed to have significant blind spots about some areas of the field. He misdiagnosed my juvenile Type 1 diabetes as an eating disorder for so long I nearly died from lack of appropriate treatment. But he was the only game in the area unless you were willing/able to drive two more towns over. He also delivered lots of babies, although I never heard anyone complain about their childbirth experience. At least we had an all-volunteer ambulance corps that was reasonably affordable.
Some people move to, or stay in remote areas either because they like it or because it’s what they’ve always known. Others live there because they lack the resources and opportunities to move anywhere else.
posted by The Underpants Monster at 9:17 PM on August 10, 2022
Some people move to, or stay in remote areas either because they like it or because it’s what they’ve always known. Others live there because they lack the resources and opportunities to move anywhere else.
posted by The Underpants Monster at 9:17 PM on August 10, 2022
I really don't mean to apologize for the status quo, just some observations.
- L&D ought to be a 24/7 service, but how much volume can rural counties provide? To have 1 person available at a moment's notice takes ~ 4.5 full-time employees. As L&D has evolved to require more specialist services, this has become less and less tenable. The article points to a lack of sonographers, specialized nurses, anesthesia services (labor epidurals) and NICU coverage in Big Bend. If the volume is so low that you can stretch to 2-3, can they maintain skills?
- The lack of universal healthcare coverage is a big one. As the article points out, payment by state-run insurance is lower than the cost. For border towns with uninsured patients with no money, the hospital is out of luck. It doesn't help that US hospitals keep fake prices and are as opaque as possible about what anything actually costs them. Government-run hospitals have an idea of what their services cost, but have trouble tracking how all the pieces work together and various subsidies fit in. The federal government provides very substantial (byzantine) subsidies for rural hospitals, including indirect ones like the above mentioned loan forgiveness for doctors and visa incentives for foreign doctors. The amount of subsidy needed to maintain staff for services that aren't being used most of the time is very large.
- L&D in the US is very concerned with litigation, and this makes hospitals afraid to have low-volume delivery practices. If you didn't have every service available or had delays while waiting for the on-call person to show up, you will probably lose that case. You can usually cover this with insurance, but that just averages out the cost over time. Insurers aren't fools and know where the risks are higher.
- Midwives and other non-physician clinicians are a fine option for most deliveries. However, if they are not backed up by hospital-level care, they will not be able to handle the unexpectedly complicated deliveries that lead to maternal and neonatal deaths or help the increasing number of women whose pregnancy is known to be complex. Every attempt at boosting the supply of non-physician clinicians sees most of them settle in cities in a similar (but less extreme) pattern as physicians, so the effect on rural care isn't that big.
Doesn't the AMA still control/artificially limit the supply of physicians in the US?
Medicare has funding limits from congress on the number of resident positions they will pay for. 80% of residents are paid for from the CMS subsidy because it usually takes more work from senior physicians to provide oversight than residents provide in direct value. The AMA is a trade organization with no actual power, and has supported recent increases to the number of residents. They advocate for restrictions on non-physician clinicians with the stated concern for quality of care, which is a transparent attempt to reduce competition for physician salaries IMO.
posted by a robot made out of meat at 7:07 AM on August 11, 2022
- L&D ought to be a 24/7 service, but how much volume can rural counties provide? To have 1 person available at a moment's notice takes ~ 4.5 full-time employees. As L&D has evolved to require more specialist services, this has become less and less tenable. The article points to a lack of sonographers, specialized nurses, anesthesia services (labor epidurals) and NICU coverage in Big Bend. If the volume is so low that you can stretch to 2-3, can they maintain skills?
- The lack of universal healthcare coverage is a big one. As the article points out, payment by state-run insurance is lower than the cost. For border towns with uninsured patients with no money, the hospital is out of luck. It doesn't help that US hospitals keep fake prices and are as opaque as possible about what anything actually costs them. Government-run hospitals have an idea of what their services cost, but have trouble tracking how all the pieces work together and various subsidies fit in. The federal government provides very substantial (byzantine) subsidies for rural hospitals, including indirect ones like the above mentioned loan forgiveness for doctors and visa incentives for foreign doctors. The amount of subsidy needed to maintain staff for services that aren't being used most of the time is very large.
- L&D in the US is very concerned with litigation, and this makes hospitals afraid to have low-volume delivery practices. If you didn't have every service available or had delays while waiting for the on-call person to show up, you will probably lose that case. You can usually cover this with insurance, but that just averages out the cost over time. Insurers aren't fools and know where the risks are higher.
- Midwives and other non-physician clinicians are a fine option for most deliveries. However, if they are not backed up by hospital-level care, they will not be able to handle the unexpectedly complicated deliveries that lead to maternal and neonatal deaths or help the increasing number of women whose pregnancy is known to be complex. Every attempt at boosting the supply of non-physician clinicians sees most of them settle in cities in a similar (but less extreme) pattern as physicians, so the effect on rural care isn't that big.
Doesn't the AMA still control/artificially limit the supply of physicians in the US?
Medicare has funding limits from congress on the number of resident positions they will pay for. 80% of residents are paid for from the CMS subsidy because it usually takes more work from senior physicians to provide oversight than residents provide in direct value. The AMA is a trade organization with no actual power, and has supported recent increases to the number of residents. They advocate for restrictions on non-physician clinicians with the stated concern for quality of care, which is a transparent attempt to reduce competition for physician salaries IMO.
posted by a robot made out of meat at 7:07 AM on August 11, 2022
As the article points out, payment by state-run insurance is lower than the cost.
s/the cost/the amount that the medical industry would prefer to receive/g
posted by GCU Sweet and Full of Grace at 8:12 AM on August 11, 2022 [1 favorite]
s/the cost/the amount that the medical industry would prefer to receive/g
posted by GCU Sweet and Full of Grace at 8:12 AM on August 11, 2022 [1 favorite]
Yes, rural hospitals are just making it up. They’re all so greedy, that’s why they close or are forced into consolidating.
posted by a robot made out of meat at 5:16 PM on August 11, 2022
posted by a robot made out of meat at 5:16 PM on August 11, 2022
Yeah people don't want to talk about how expensive healthcare is, especially the litigation part of it. I'm familiar with the workings of a missionary founded not-for-profit hospital that puts 100% of its revenues back into patient care - and since it's not publicly funded - during Covid they were asking each incoming Covid inpatient for an upfront cash deposit larger than the GDP per capita of the country, because that's what a sick Covid patient would actually cost in terms of pure labor / equipment.
(People were paying that because the publicly funded hospitals were absolutely swamped).
posted by xdvesper at 6:40 PM on August 11, 2022
(People were paying that because the publicly funded hospitals were absolutely swamped).
posted by xdvesper at 6:40 PM on August 11, 2022
Yes, rural hospitals are just making it up.
That's a fair cop, and I'm sorry.
I should have just said that "the costs" are not set in stone. There is no fundamental law of nature that requires health care to be a Coasian nightmare. There is no fundamental law of nature that requires pharmaceuticals and other supplies to be grossly overcharged. There is no fundamental law of nature that requires us to produce only a few physicians who are paid very highly. Etc.
posted by GCU Sweet and Full of Grace at 7:30 PM on August 11, 2022 [2 favorites]
That's a fair cop, and I'm sorry.
I should have just said that "the costs" are not set in stone. There is no fundamental law of nature that requires health care to be a Coasian nightmare. There is no fundamental law of nature that requires pharmaceuticals and other supplies to be grossly overcharged. There is no fundamental law of nature that requires us to produce only a few physicians who are paid very highly. Etc.
posted by GCU Sweet and Full of Grace at 7:30 PM on August 11, 2022 [2 favorites]
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